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Can Psychotherapists Function as Their Own Controls? Meta-Analysis of the Crossed Therapist Design in Comparative Psychotherapy Trials

Fredrik Falkenström, PhD; John C. Markowitz, MD; Hanske Jonker, MSc; Björn Philips, PhD; and Rolf Holmqvist, PhD

Published: October 30, 2012

Article Abstract

Objective: Clinical trials sometimes have the same therapists deliver more than 1 psychotherapy, ostensibly to control for therapist effects. This “crossed therapist” design makes controlling for therapist allegiance imperative, as therapists may prefer one treatment they deliver to the other(s). Research has established a strong relationship between principal investigators’ allegiances and treatment outcome. Study therapists’ allegiances probably also influence outcome, yet this moderating factor on outcome has never been studied.

Data Sources: English language abstracts in PsycINFO and MEDLINE from January 1985 to December 2011 were searched for keywords psychotherapy and randomized trial.

Study Selection: The search yielded 990 abstracts that were searched manually. Trials using the same therapists in more than 1 condition were included.

Data Extraction:Thirty-nine studies fulfilled inclusion criteria. Meta-regression analyses assessed the influence of researchers’ allegiance on treatment outcome, testing the hypothesis that studies poorly controlling for therapist allegiance would show stronger influence of researcher allegiance on outcome. A single-item measure assessed researchers’ reported attempts to control for therapist allegiance.

Results: Only 1 of 39 studies (3%) measured therapist treatment allegiance. Another 5 (13%) mentioned controlling for, without formally assessing, therapist allegiance. Most publications (67%) did not even mention therapist allegiance. In studies not controlling for therapist allegiance, researcher allegiance strongly influenced outcome, whereas studies reporting control for therapist allegiance showed no differential researcher allegiance. Researchers with cognitive-behavioral therapy allegiance described controlling for therapist allegiance less frequently than other researchers.

Conclusions: The crossed therapist design is subject to bias due to differential psychotherapist allegiance. Worrisome results suggest that researchers strongly allied to a treatment may ignore therapist allegiance, potentially skewing outcomes. All clinical trials, and especially crossed therapist designs, should measure psychotherapist allegiance to evaluate this possible bias.

J Clin Psychiatry

Submitted: April 12, 2012; accepted August 10, 2012.

Online ahead of print: October 30, 2012 (doi:10.4088/JCP.12r07848).

Corresponding author: Fredrik Falkenström, PhD, Lustigkullevägen 17, SE-616 33 Šby, Sweden (

Volume: 73

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